1. Rural West Primary Health Care (PHC) Team December 9 – 10, Calgary

2. Vision of the Rural West PHC Team Quality client focused health care in an accessible and timely manner by a coordinated multi-disciplinary team tailored to the client’s needs.”

3. There is a need for the Rural West PHC Team: to deliver client-centered, quality care to a large geographic area to use the most appropriate professional for the concern to move health care in the rural area forward to meet the needs of the communities

4. Where is the Rural West PHC Team providing service? The area west of Weyburn, Saskatchewan (in the Sun Country Health Region) Includes all of the communities located within the box

5. Rural West: Area Snapshot 8 Rural Municipalities 5 villages 4 Towns Covered population – 3772 Patterns of care - 4097 Population of Health Region – 54 032 Size of Belgium

6. Rural West: Community Snapshot ( Information based on community consultations ) Radville Population - 780 Services – Physicians, full business community, K-12 school, recreation, health centre Strengths – health care team in place, strong business community, active community, resilient community. Challenges – getting residents to buy into new model of health care, communication about what services/programs we have and how to access them. Gladmar Population – 81 Services - One store that holds post office, gas, general store, K-12 school, recreation Strengths – strong sense of community, support community members. Challenges – geographical area, emergency services, roads, transportation, communication

7. Providing Primary Care in Rural West Communities is about: keeping communities healthy preventing illness and injury managing chronic conditions treating acute medical illness promoting healthier living accessing the best provider for the job

8. Who is the Rural West PHC Team? Client(s) Physicians Nurse Practitioners Registered Nurses Pharmacists Dietitians Community Partners Occupational & Physical Therapists Home Care Social Work Mental Health Public Health All Support Services Speech/Language Pathologist

9. A day in the life of ….. Physician Team members

10. Rural West PHC Team believes that Primary Health Care is achieved by: integrated, interdisciplinary teams including community members providing quality service providing service at the right time and place enabling, encouraging clients to manage/maintain their health addressing the determinants of health

11. Our Focus: Client – Centered Care Management of Chronic Disease Disease Prevention and Health Promotion Population Health Strategies Elements of Quality Primary Care: Accessibility; Effectiveness; Equity; Appropriateness; Efficiency; and Safety

12. How will the Rural West PHC Team do this? The team will: focus on what is going on in the community. What do they say they need? take a broad look at Determinants of Health & Inter-sectoral approaches. –Is everyone involved that needs to be? Who has a stake in the issue? collaborate to solve a problem

13. Our Approach: The team approach to Management of Chronic Disease would be to: ensure better education control disease progression provide coping strategies for individuals and families reduce hospital admissions

14. The team approach to Disease Prevention & Health Promotion would be to: address determinants of health create teams: health professionals, individuals, families, interest groups, schools, industry, and the community require community problem solving strengthen partnerships with all stakeholders

15. The team approach to Population Health would: address the entire range of determinants of health be designed to affect entire population require community involvement in identifying needs require links to all stakeholders

16. What does the Rural West PHC Team hope to achieve? The team aims to: Share client care improve follow-up and treatment for chronic conditions based on best practice guidelines improve case management for clients with complex needs ensure care is provided by professionals who can best meet the needs of the client

17. What does the Rural West PHC Team hope to achieve? The team aims to: reinforce the importance of every team member improve screening and monitoring programs to support early detection and intervention share information; reduce duplication support and enable self-care

18. Priorities Identified for Rural West PHC Team 2009-10 Electronic Health Record Establish case conference process for discharge Community Consultations – for community input on our Team 3 – 5 year plan Needs assessment (programs and services in the Rural West area

19. What do we hope to gain: Tools and techniques to address our challenges – geographical area and building teams across the large area Building capacity for effective teamwork Facilitate communication ( within team, departments, roles and responsibility, private sector, with community) Information sharing (best practice for providers to share info) Sustaining collaboration

21. Questions?